Transcript PN1lab notes\TPR and Peripheral Pulses

TPR and Peripheral Pulses
PN 1 Nursing Skill Labs
Equipment
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glass thermometer - consider mercury
spills
electronic thermometer
tympanic thermometer
others - patch, tape, single use
watch
paper and pen for recording
Sites and Methods
Oral
 wait 15 – 30 min after hot or cold drink
smoking or chewing gum
 do not use oral site if
• unconscious
• seizure prone
• irrational
• child - very young
• O by mask
• recent oral surgery
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if using glass thermometer, shake down
and wipe down!!
place in sublingual pocket and close lips
must wait 3 minutes when using glass
thermometer; others alarm or indicate
when ready
always indicate the site used in your
documentation
Rectal (not used for newborns!!)
 shake down and wipe glass thermometer
and insert 1 1/2 inches (adults) after
lubricating well!!! (check depth
depending on age/size) - hold 2-3 mins
 hold thermometer in place to ensure
accurate reading
 considered most accurate reflection of
core temp
Axilla
 if using glass thermometer, shake, wipe
and hold for 10 mins
 make sure axilla is dry
 place tip of thermometer in center of
axilla and place arm close to body
 considered as accurate as oral or rectal
when done correctly
Tympanic
 pull pina up and back (for adults)
 most common site currently used
 uses infrared sensers
 does not actually touch the typmanic
membrane
Factors affecting Pulse Rate &
Rhythm
Tachycardia
 pulse of 100 - 180 bpm
 may be caused by pain, emotions,
exercise, prolonged heat, decreased
blood pressure, pyrexia, reduced O2 in
blood, some medications
Bradycardia
 pulse below 60 bpm
 pulse is generally slower at rest
 may be related to thin body size, gender
( males slower than females), increased
age and some medications
 this is often considered normal for
people in great physical shape!!
Equipment
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Stethoscope, doppler, cardiac monitor
cleanse earpieces with alcohol swab
warm before use
point ear pieces toward nose
ensure bell is “on”
bell – low freq. Heart & BP
diaphragm – hi freq. Resp & bowel
sounds
watch with second hand
Sites and methods
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never use your thumb to palpate a pulse
use the pads of three middle fingers
count for 1 full minute
exception - if peripheral pulse irregular
or abnormal for that patient repeat at
apical site and count for 1 full minute
Pulse deficit = difference between
apical and radial pulse
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Radial
• ease of access, circulation of hand
• make sure arm is resting comfortably
Carotid
• most easily palpable if blood pressure is
low (only palpate one side at a time)
Apical
• audible with stethoscope
• measured at 5th intercostal space,
slightly left of pts. midclavicular line
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Brachial - used in infants
Femoral - often used in cardiac arrests
Popliteal - peripheral circulation
Posterior tibial (tibial) and Dorsalis pedis
(pedal) - assesses peripheral circulation
always document location of pulse
assessment
Pulse Points
Respirations
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one respiratory cycle = from beginning of
one inspiration to beginning of the next
inspiration
important that patient not be aware you
are counting his/her respirations
normal ratio is 1 breath to 4 heartbeats
count for 1 full minute
document rate and depth
Factors affecting Respiration
Increases
  rate if in pain
  in BMR
 exercise
 sympathetic
stimulation
 smoking
 require more oxygen
 pyrexia
Decreases
  depth if in pain
 pathologies
 sedatives and
analgesics
 parasympathetic
 relaxation
 increased ICP
Terms related to Respiration
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tachypnea - rapid > 24 per min
bradypnea - slow < 10 per min
apnea - periods of no breathing
- brain damage in 4-6 mins
orthopnea - breathing easier in
upright position
dyspnea - labored or difficult
breathing
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hyperventilation - increased rate and
depth
hypoventilation - decreased rate and
depth
Cheyne-Stokes - deep rapid breathing
followed by periods of apnea